Provider Demographics
NPI:1770863326
Name:FAIRBANKS, ALEXIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 BROAD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-9662
Mailing Address - Country:US
Mailing Address - Phone:803-749-3046
Mailing Address - Fax:
Practice Address - Street 1:7412 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-9662
Practice Address - Country:US
Practice Address - Phone:803-749-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist